Gwent Public Services Board

Response Analysis Template

 

On 10 March 2022, Gwent Public Services Board (PSB) made the decision to become a ‘Marmot Region’, and to use the social determinants of health approach as the basis for the response to well-being and health inequalities in Gwent.  A copy of the Marmot proposal paper is available at:

https://www.gwentpsb.org/wp-content/uploads/2022/03/03-Proposal-Gwent-Becoming-a-Marmot-Region.pdf

1.    Theme: Health and Well-being & Health Inequalities (inc. Housing)

The ABUHB Director of Public Health Annual Report 2019, ‘Building a Healthier Gwent’1, described the scale of the strategic challenge to reduce health inequalities.  For people in all communities in Gwent to live healthy, fulfilled, dignified lives, means going further to reduce the inequality gap in the number of years lived in good health between the most and least deprived communities.

 

The Gwent Well-being Assessment (2022)2 highlights the significant inequalities across communities in Gwent, whether measured by health, education, employment, or home ownership. It also demonstrates the impact of poor housing quality, which drives fuel poverty, and exacerbates health inequalities. The Gwent Well-being Assessment highlights the breadth of action necessary to narrow health inequalities between communities across Gwent. The eight Marmot Principles provide a framework for a programme of action:

 

1.    Give every child the best start in life

2.    Enable all children, young people and adults to maximise their capabilities and have control of their lives

3.    Create fair employment and good work for all

4.    Ensure a healthy standard of living for all

5.    Create and develop healthy and sustainable places and communities

6.    Strengthen the role and impact of ill health prevention

7.    Tackle racism, discrimination and their outcomes

8.    Pursue environmental sustainability and health equity together

 

2.    Outline of the issues

 

Gwent’s assets are a diverse economy, rich culture and heritage, iconic natural environment and strong communities. However, there are significant inequalities in health, education, housing, income and employment which collectively result in socio-economic deprivation. The Gwent Well-being Assessment (2022) shows that the highest levels of socio-economic deprivation are located in the valleys and Newport city centre communities.

Gwent has a high proportion of residents with limiting long-term illness, and high premature death rates in the parts of the region with high levels of socio-economic deprivation.  Over the period 2011-13 to 2018-20, for both men and women, the inequality gap in life expectancy (between the most and least deprived communities) has remained unchanged, and there continues to be a seven year gap for men and a six year gap for women. The gap in healthy life expectancy is also largely unchanged for men (13 years), but it has widened for women such that the gap is now 20 years. This means that a woman living in the most deprived part of Gwent today lives just 48 years of life in good health.3

 

Figure 1: Life expectancy at birth (years), most vs least deprived quintiles, Aneurin Bevan University Health Board area, 2011-13 to 2018-20.

Source: Public Health Wales

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 2: Healthy life expectancy at birth (years), most vs least deprived quintiles, Aneurin Bevan University Health Board area, 2011-13 to 2018-20.

Source: Public Health Wales

 

For people in all communities in Gwent to live healthy, fulfilled, dignified lives means reducing the inequality gap. This will need all of Gwent’s public, private and voluntary sector to work together with communities to address the social determinants of health.  Housing should be health-improving, climate-change resilient and suitable for an ageing population.  Communities should be safe, with a focus on well-being and empowerment.  Education should result in more equitable opportunities and narrow the attainment gap.  Transport should enable access to employment, education, culture and leisure, and be health and climate-improving.  Employment should provide a fair income and good, health-improving and protecting work, and be climate change resilient.  The environment should promote well-being, and be protected from biodiversity loss and climate change.

 

The opportunities and challenges identified in the Gwent Well-being Assessment are set against the backdrop of what has been described as the ‘triple challenge’ of the Covid-19 pandemic, the UK leaving the European Union, and the climate emergency.4 This is further intensified by the heightening cost of living crisis. Whilst the long-term impacts are not yet known, these factors all have the potential to further widen inequalities.

 

By becoming a Marmot region, Gwent will work across the wide range of social determinants for a healthy society.  Professor Sir Michael Marmot (Director of the UCL Institute of Health Equity) has developed eight Marmot Principles for achieving greater equity in health. He first proposed his original six principles in his Strategic Review of Health Inequalities in England (2010), ‘Fair Society, Healthy Lives’, which illustrated in detail that the more deprived the area, the shorter the life expectancy.5 Professor Marmot has continued to advocate these guiding principles as the framework for action in his subsequent reviews of health inequalities in England, including in Marmot communities and regions (see Gwent PSB Marmot proposal for further information and references). In his most recent report, ‘All Together Fairer: Health Equity and the Social Determinants of Health in Cheshire and Merseyside’, Professor Marmot advocates for the inclusion of two additional principles (see principles 7&8 in Section 1).6

 

The table below highlights the fit between the 8 Marmot Principles and the 15 issues for response in Gwent’s Well-being Assessment:

 

Table 1: The Marmot Principles and ‘fit’ with the Well-being Assessment

 

#

Marmot principles

Gwent Well-being Assessment - Issues for response

1

Give every child the best start in life

 

Future housing and thermally efficient existing homes

Supportive local economies

Food

2

Enable all children, young people and adults to maximise their capabilities and have control of their lives

 

Future transport modes and infrastructure

Future housing and thermally efficient existing homes

Supportive local economies

Food

Skills for the future

Digital futures

3

Create fair employment and good work for all

 

Future transport modes and infrastructure

Supportive local economies

Skills for the future

Digital futures

4

Ensure a healthy standard of living for all

 

Future transport modes and infrastructure

Future housing and thermally efficient existing homes

Supportive local economies

Food

5

Create and develop healthy and sustainable places and communities

 

Community safety

Cohesive and empowered communities

Future transport modes and infrastructure

Future housing and thermally efficient existing homes

Supportive local economies

Food

Flood risk

6

Strengthen the role and impact of ill health prevention

 

Covid-19

Future housing and thermally efficient existing homes

Supportive local economies

Food

7

Pursue environmental sustainability and health equity together

Climate change – adaptation and mitigation

Biodiversity and species loss

Ecological footprint

Future housing and thermally efficient existing homes

Supportive local economies

Food

Skills for the future

Flood risk

Digital futures

8

Tackle racism, discrimination and their outcomes

Cohesive and empowered communities

Future housing and thermally efficient existing homes

Supportive local economies

Skills for the future

Digital futures

 

·       Housing

As noted in the table above, a recurring element to addressing inequalities is future housing and thermally efficient existing homes.

The advisory group for the UK Committee on Climate Change, chaired by Professor Sir Michael Marmot, produced the report titled “Sustainable Health Equity: A Net Zero UK,” in 2020.7 The report noted that living in a cold home that is difficult or expensive to heat increases the risk of exposure to cold and is associated with a variety of health impacts, especially respiratory infections -   the leading cause of excess winter mortality.   

Poor housing also has well evidenced effects on mental health in adults, including worry about debt and affordability and stress due to cold and damp environments. Fuel poverty has also been associated with poorer respiratory health and depressive symptoms. Conversely, warm homes have been found to contribute to reductions in the incidence of cardiovascular disease, cardiopulmonary disease, lung cancer and childhood asthmas and improved mental health and well-being. 8,9,10,11

It is estimated that close to one-third of excess winter deaths are attributable to living in a cold home. Cold-related deaths are more likely in older properties and homes with the poorest thermal efficiency ratings, and among older occupants. Overall, cold homes follow the social gradient: the lower a person’s socioeconomic status, the more likely that they will live in a cold home. 8,9,10,11

Actively reducing exposure to cold homes through improving their thermal and energy efficiency has also been found to contribute to wider social and health benefits, including: 8,9,10,11

·                   Delaying and reducing the need for primary care and social care

·                   Preventing hospital admissions

·                   Increased school attendance

·                   Increased engagement with (community and social) services

·                   Reduced incidence of risky health-related behaviours

·                   Enabling timely discharge from hospital, and preventing re-admissions

·                   Enabling rapid recovery from periods of ill health or planned admissions.

 

 

 

 

3.    Well-being objectives to be worked towards under this priority:

 

Table 1 above lists the eight Marmot Principles that will be worked towards as well-being objectives under this priority theme within the Gwent Well-being Plan. 

4.    What contribution can working towards these objectives achieve for well-being in Gwent?

 

·       Why do it - what is the case for prioritising work on this issue?

 

There is a 13 year difference for men and a difference which has widened to 20 years for women in how long life is lived in good health between the richest and poorest neighbourhoods in Gwent.  The gap in life expectancy between the most and least deprived neighbourhoods is approximately 7 years for men and 6 years for women.3  This is unjust, unfair and amenable to action by Gwent PSB partners.     

 

·       Is it an issue that could be tackled over the short, medium or long-term?

 

Reducing health inequalities in Gwent by addressing the social determinants of health, and the historical legacy of housing, will require a cross-sector response which includes actions for the short, medium and long-term. Long-term will be up to 25 years ahead, in line with the definition in the Well-being of Future Generations Act (Wales) Act (2015).

 

·       How could it contribute to the 7 Well-being Goals?

 

The table below highlights the contribution of the eight Marmot Principles to Wales’ seven well-being goals.

 

Table 2:  The 8 Marmot Principles and the 7 Well-being Goals

 

#

Marmot principles

Well-being goals

1

Give every child the best start in life

 

Healthier

More Equal

Cohesive Communities

Vibrant Culture and Thriving Welsh Language

2

Enable all children, young people and adults to maximise their capabilities and have control of their lives

 

Prosperous

Healthier

More Equal

Cohesive Communities

Vibrant Culture and Thriving Welsh Language

3

Create fair employment and good work for all

 

Prosperous

Resilient

Healthier

More Equal

Cohesive Communities

Vibrant Culture and Thriving Welsh Language

Globally Responsible

4

Ensure a healthy standard of living for all

 

Healthier

More Equal

Cohesive Communities

Vibrant Culture and Thriving Welsh Language

5

Create and develop healthy and sustainable places and communities

 

Resilient

Healthier

More Equal

Cohesive Communities

Vibrant Culture and Thriving Welsh Language

Globally Responsible

6

Strengthen the role and impact of ill health prevention

 

Healthier

More Equal

Cohesive Communities

Vibrant Culture and Thriving Welsh Language

7

Pursue environmental sustainability and health equity together

 

Prosperous

Resilient

Healthier

More Equal

Cohesive Communities

Vibrant Culture and Thriving Welsh Language

Globally Responsible

8

Tackle racism, discrimination and their outcomes

 

Prosperous

Healthier

More Equal

Cohesive Communities

Vibrant Culture and Thriving Welsh Language

Globally Responsible

5.    Where are we now?

 

·       Evidence of current situation – data, research, etc.

 

The current situation is set out in both the Gwent Well-being Assessment2 and the proposal for Gwent to become a Marmot region (link on page 1), including the health inequalities ‘headlines’ in section 4 above.

 

As illustrated in the local government diagram below, local authorities have an influence in every social determinant of health, with some services, e.g. Planning, influencing more than one determinant of the health and well-being of the local population.12

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 3: Local government and the social determinants of health and well-being

 

Source: Local Government Association (2020)  

 

·       What is currently being done and by whom?

 

The table in Annex 1 shows the linkages between the 2018-23 local well-being objectives for the five former PSBs in the Gwent region and the Marmot Principles. The table in Annex 2 shows examples of linkages between the delivery programmes of the five former PSBs in the Gwent region and the Marmot Principles. Both tables are informed by published documents from the five former Gwent PSBs.

 

·       Do we have a comprehensive picture of all activity e.g. private sector, third sector, community interventions?

 

There will be a whole host of interventions in place currently.  Some interventions Gwent PSB partners will be aware of as either funded programmes or areas of direct delivery.  Some will be happening as a result of less formal community action which Gwent PSB partners may not be aware of.  A picture of what is happening, and crucially what is the impact, will need to be explored further with the Institute of Health Equity during the first year of the Well-being Plan. 

 

There is a need to strengthen business sector involvement and collaboration in the Marmot programme. Business and the economy has a key part to play in improving social conditions that affect health and health equity, including employment conditions, goods and services, and wider impacts.13

 

South Wales Fire and Rescue Service are ensuring all children receive education at Key Stage 1&2 on fire safety in the home. Adults deemed most vulnerable to accidental fires have comprehensive home fire safety checks.

 

Examples of work underway in Newport City Council are listed in Annex 3. 

 

In respect of tackling the historic legacy of the poor thermal efficiency of the existing housing stock in Gwent, progress is being made.  With the target set by Welsh Government, informed by the research “Better Homes, Better Wales, Better World – decarbonising the existing homes in Wales14, the social housing sector is leading in this area. As noted above, from the report titled “Sustainable Health Equity: A Net Zero UK”7 it highlights the importance of improving thermal efficiency, and the decarbonisation programme that flows from the Welsh Government targets will address a number of the eight Marmot Principles.  This is illustrated below:

 

Table 3:  Housing and impact on the eight Marmot Principles

 

#

Marmot principles

1

Give every child the best start in life

 

 

Decarbonisation of existing homes (i.e. improve the thermal efficiency) supports the healthier well-being goals of reducing health inequalities that living in a cold home that is difficult or expensive to heat, or both, increases the risk of exposure to cold and is associated with a variety of health impacts

3

Create fair employment and good work for all

 

 

Decarbonisation of existing homes (i.e. improve the thermal efficiency) supports the prosperous well-being goals as the target requires retrofitting of the affordable housing sector by 2030 at a cost of up to Ł1bn, which in turn will create a significant number of new green jobs in the region.  This is sustainable as that programme will continue after 2030 with home owners seeking such improvements (the demand enhanced by the 2022 cost of living crisis impact on energy costs).

4

Ensure a healthy standard of living for all